Mannequin distorted in mirrorBody image, in most modern definitions, involves two key elements: a mental picture of one’s physical body (including size, shape, and appearance), and one’s attitude toward the physical self (such as thoughts, feelings and beliefs about one’s body). Body image may change gradually and can be influenced by a number of social factors, such as culture, the media, and interactions with family and friends. It also often adapts to reflect new information, people, and experiences. 

A negative or unhealthy body image can contribute to low self-esteem and affect well-being. When the mental image of one’s body or one’s attitude toward this image causes distress or interferes with function, a mental health professional may be able to help explore and address these concerns. 

Positive vs. Negative Body Image

Most individuals have experienced the desire to modify some aspect of their appearance: hair that is too curly, a nose that is too long, or a scar that does not fade, for example. In many cases, these perceived imperfections do not create significant anxiety and have little impact on a person’s overall sense of self. Individuals who accept and love their bodies without dwelling on what they believe to be flaws can be said to have a generally positive or healthy body image.  

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Some people might modify parts of the body they do not like: cover freckles with makeup, use hair loss treatment, work out, and so on. These actions do not necessarily imply one has a negative body image. According to Ondina Hatvany, LMFT, a "healthy body image means you are comfortable with the body you have. It does not mean you think your body is perfect, rather, that you accept it and commit to loving and caring for it."

Individuals who have what can be considered a negative or unhealthy body image tend to become preoccupied with what they feel to be bodily flaws and may have a distorted perception of physical features. They may feel uncomfortable in their own bodies; find it difficult to accept the way they look; or experience discomfort, dissatisfaction, shame, or even disgust in relation to their appearance."Healthy body image means you are comfortable with the body you have. It does not mean you think your body is perfect, rather, that you accept it and commit to loving and caring for it."

Though some may have a predominantly positive body image and others may more often feel negatively about their bodies, body image is not typically something neatly categorized into one of two categories. More accurately, body image can be said to be experienced along a continuum. Most individuals experience different degrees of positive and negative feelings about their bodies at different times. Further, body image is subjective and does not always reflect reality: One’s mental image of one’s own body may therefore be at odds with what an outside observer sees.

Body Image and the Media

Media can have a powerful influence on body image. Television, advertisements, pop culture icons, and other media can all have a powerful impact on how people regard their bodies. Conventionally attractive people with idealized features and bodies seem to present an “ideal” body type, and advertisements often suggest everyone can achieve a similar body, face, or look, if they only make the effort. Overt and covert messages along these lines appear frequently in the media. “You only have to turn the TV on for five minutes to hear the message that if we look a certain way, we, too, can have that stellar-looking partner hanging off our arm or that perfect dream job. In fact, all we have to do is buy the advertised shampoo, get the right hair, attain the correct weight, and all the love, success, and glory we desire will follow!” Hatvany says. 

These messages may be harmful because the standards of physical attractiveness portrayed by the media are sometimes fairly inflexible and may not be attainable by all. A person can dye or cut hair with relative ease, use colored contacts to change eye color, and attain a more toned physique at the gym. However, other characteristics such as facial structure, body shape, and voice may be more difficult to change, and costly procedures may be required in order to do so. Some aspects of a person’s body, such as height, are unable to be altered. 

Still, many individuals may compare their bodies to the types of bodies portrayed as ideal, and this can lead to dissatisfaction. In some cases, a person may become fixated on the idea of attaining the “perfect body” and engage in extensive or extreme behaviors, such as excessive dieting and exercise or repeated cosmetic surgery, in order to achieve the desired body. This behavior may place individuals at risk of mental health concerns such as depressionanxiety, and eating disorders

Man trying on clothes

Although the media often places more emphasis on the ideal female form, an increasing number of ads and images also feature what is considered by popular opinion to be the perfect male physique. Interestingly, this heightened focus on standards of male attractiveness coincides with an increase in the number of men who experience negative body image. While women tend to report greater concern about facial features, weight, shape, breasts, thighs, and buttocks, men are generally more concerned about height, muscle definition, and signs of thinning hair. To achieve the desired body type, they may work out to a degree that could be considered extreme or use anabolic steroids to increase muscle mass. In recent years, men have also opted to modify their features with cosmetic surgery in greater numbers than they have in the past. 

Body Image and Self-Esteem

Body image and self-esteem are related but distinct concepts. Body image describes one's attitude toward a single aspect of the self, namely the physical body, while self-esteem relates to one's view of the self as a whole. Self-esteem may involve an evaluation of one's overall worth and is generally not limited to the physical body. Nevertheless, the way people think and feel about their bodies is often strongly connected to their overall view of themselves. 

A number of studies, conducted across various age groups, have consistently demonstrated a positive relationship between self-esteem and body image. In other words, higher self-esteem is linked to a more positive body image, while lower self-esteem is associated with a more negative body image. However, research has not yet determined the direction of the relationship. Body image may be lowered by poor self-esteem, but a negative body image might just as easily lead to low self-esteem. Most researchers agree both possibilities are plausible. 

People with low self-esteem tend to be more critical of their own appearance and are often more likely to engage in negative comparisons of themselves with others, an action shown to increase the likelihood of body dissatisfaction. On the other hand, those who experience a more negative body image may become preoccupied with their appearance and are less likely to focus on personal strengths in other areas, which may result in a less favorable evaluation of self-worth. 

"When you have a number of different things that you value about yourself, your view of yourself will also be more stable, steady, and solid."

Despite the strong association between self-esteem and body image, a decline in one’s body image does not necessarily produce a corresponding change in self-esteem. The extent to which one’s self-esteem is built on a broad base as opposed to a narrow base is considered to be an important moderating factor. A narrow basis for self-esteem exists "when your self-esteem is based solely on one thing, such as how you look or how much you weigh. With such a narrow base, your self-esteem is much more vulnerable to collapse," Hatvany explains. "On the other hand, a wide basis for self-esteem exists when there are other qualities that form a foundation for your self-esteem. These qualities might include your fabulous personality, your talents and gifts, your smile, your contribution to your community, your culture etc. When you have a number of different things that you value about yourself, your view of yourself will also be more stable, steady, and solid." 

Body Image Distortion and Dissatisfaction

Since body image is typically based more on perceptions and feelings than on actual appearance, it can be vulnerable to distortion. Body image distortion refers to a misperception of one or more features of the body. It usually involves a significant discrepancy between the perceived size and shape of one's body or one or more aspects of the body and the actual shape and size of the body or its features. People experiencing body image distortion may see a body in the mirror that is significantly different from their actual physical body. 

Body image dissatisfaction generally involves negative evaluations of one's body and can occur when a discrepancy is perceived between one's body and one's ideal body. Body dissatisfaction is often associated with body image distortion, but these two states are not necessarily linked. A person might be dissatisfied with some aspect of physical appearance without experiencing body image distortion and might also experience a distorted perception of some bodily feature without first experiencing dissatisfaction. Similarly, one may be dissatisfied with one's appearance, or certain aspects of it, without experiencing a related misperception. 

Body Image and Disordered Eating 

Individuals who have a body image that might be considered unhealthy may subject themselves to intense internal scrutiny and become fixated on perceived physical imperfections. They may have unrealistic goals regarding weight and size and may, in pursuit of these goals, take actions that might be considered extreme by some. These actions often include overeating, starving oneself, binge eating, and purging. Body image disturbance may also contribute to serious eating problems such as anorexia nervosa and bulimia

Both body image distortion and body dissatisfaction are positively correlated with disordered eating, although the relative influence these factors have on the condition is still unclear. Body dissatisfaction has been cited as the single strongest predictor of disordered eating among women, but recent research suggests that body image distortion may be a better predictor of unhealthy eating patterns, at least among teenage girls. 

Body Dysmorphic Disorder (BDD)

Goldfish's reflection distorted in glassBDD is a severe form of body image disturbance in which individuals become preoccupied with some perceived flaw in their physical appearance or display concern with minor physical irregularities to an extent that can be considered excessive. They may experience a distorted view of their body and may worry some feature of their appearance is unattractive or disproportionate to other body parts. Their fixation on these minor or nonexistent defects may become severe enough to interfere with normal function and can often cause significant personal and social distress. 

Often beginning in the teenage years, BDD is estimated to affect one in 200 individuals. Individuals with BDD usually experience dissatisfaction related to specific parts of their bodies, such as facial features, hair, or genitalia, rather than dissatisfaction with overall shape, size, or weight, as is often experienced by those diagnosed with an eating disorder. Further, people with BDD may become so uncomfortable with the thought of others noticing perceived flaws that attempt to cover them with clothing or makeup. In some cases, those with BDD may avoid social contact altogether and refuse to leave their homes. Nearly half of all individuals diagnosed with BDD will seek plastic surgery to correct perceived defects.

Addressing Body Image in Therapy

Concerns related to one's body image can often be explored in therapy, and cognitive behavioral therapy (CBT) has been shown to be effective at treating concerns related to a body image that may be having a negative impact on an individual's well-being. 

The aim of the therapy is to reduce preoccupation with perceived flaws and help the individual in treatment to develop a more realistic and positive perception of the body. CBT often involves psychoeducation, which aims to help individuals become aware of the nature of body image and of the role that certain factors play in the development of their personal body image. In therapy, individuals may be encouraged to engage in self-monitoring, often by keeping a diary, in order to become more aware of both the negative and positive thoughts and emotions regarding their body, as well as the factors that trigger them. By means of cognitive restructuring, the therapist can help individuals to modify thoughts, feelings, and behaviors that may be unhealthy, and individuals may become better able to accept and love their bodies as a result. 

A number studies have demonstrated the efficacy of body image CBT across several treatment modalities, namely individual therapy, group therapy, and self-administered treatment. 

Case Example

  • Addressing body image distortion in therapy: Isaiah, 26, enters therapy, reporting anxiety and distress as a result of his "flawed" face. He believes his nose to be off-center, his ears crooked, and his eyes uneven. Everyone he asks assures him his features are even, which, he tells the therapist, makes him angry. When he looks in the mirror, he reports, he feels ill and disgusted and "cannot bear" to look at himself. Because of his distress, he has lately found it difficult to go out, see people, or engage in daily activities. He has been able to work, since he has a job where he is by himself for much of the day, but he admits to the therapist that he often feels as if people are whispering about his looks behind his back. He feels certain that everyone believes him to be hideous and thus does not attempt to date. Isaiah tells the therapist he has been saving money in order to get plastic surgery, as he believes this is the only way he will be able to relieve his distress. However, the thought of the amount of time it will take him to save the necessary amount further contributes to his low mood. The therapist helps Isaiah explore the onset of his distress in order to better understand it and works with him in an attempt to relieve some of the anxiety he is experiencing. She encourages him to keep a journal of his feelings and note any times when he experiences distress more or less intensely. Talking through his feelings in therapy with a supportive therapist who does not discount his distress or tell him he "looks fine" helps Isaiah to be able to achieve some level of relief. It takes several sessions, but eventually he is able to look in a mirror without experiencing extreme disgust, and he achieves some measure of acceptance of his features, though he does still experience periods of lowness related to his distorted perception. After several weeks of CBT, Isaiah reports to the therapist he is able to look up at people when he goes out in public. His desire for plastic surgery still exists, but the compulsion to obtain it at any cost has abated.


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